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~ SAN JOAQU•COUNT•Y ENVIRONMENTAL HEALTREPARTMENT <br /> SERVICE REQUEST <br /> �, hype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> y s� QiNNER'I OPERATOR <br /> ,,,,, ,;,,,,,',.. y . .1.._.,.�. .. CHECK If'BILLING.ADDRES ❑ <br /> FAblrtrY`f+}7lTtEo <br /> -- <br /> • p q F.' .• <br /> rSt E 41 ADD- sst \ — <br /> r- Street Number- Directions Street Name ` t( . <br /> §'moi`' Hp#1E�bC MAILING ADDRESS (If Different from Site Address) - - <br /> t bbr wi. �e.w.� Street Number Street Name <br /> STATE ZIP <br /> :Npgsr i,�'tH'1's <br /> 1 +. ,. <br /> NONE#t - APN# ' LAND USE APPLICATION#.x•`P110NE42:1- E%r BOS DISTRICT LOCATION CODE <br /> )1 a a l 0 l <br /> q+ 0.^214 y N� <br /> CONTRACTOR/SERVICE REQUESTOR <br /> rtrfiERUESTOR <br /> K4 CHECK If BILLING/iDDRE55� -r .. _ <br /> PHONE <br /> "61iSIt1Ea§NA7AEt n uxi 9(9l'Lo331 <br /> T� �HONIE'pr tUtAILING .W. RES$ .. .. - FAX# <br /> 4 ?CITY ': STATE zip <br /> y fLBIL ,ING:ACI iXd6YVL i7 MENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> aedI dge that all site andlorp gleot specific E waoNMENTAL HEALTH DEPARTMENT hourlychargesassociated with this project or <br /> K Bctivlty Tvill be billed.#o me oz my business.as.identified_on.this form <br /> R } <br /> also cpLtify tbatlhavcpreparedthis application and that the work to be performed will be done in accordance with all SAN TUAQUIN <br /> prdtr(ancg+Co<1�r,gfcquiards,STATE and FEDEw,laws. <br /> r - y <br /> l t ) DATE: <br /> r s4' 'A??�LIC2INT'S'SIGNATURE.: {,�� <br /> L1\' <br /> �+M�: PSkOPF,RTY./_'BUSINESS OWNERL7 , OPERrtTOR1 NL+NAGEIi-0. DTTn:A AUTHORIZED AGRNTIA_���LX_y <br /> 1fAPPLICANI Isnot the BlGtING PARTY proof of authorization to sign is required Title <br /> }�I�'AIJTHOFIZATION TO RE��VVF_,��„ <br /> :-When ap_licable,T, tlie_owner or_operator of fhepraperty located_at the <br /> a ab6t�slke�trTc�htss hereiy'autlidriz0 re base ofauy, -all results; geot c cal data an or environmental/site assessment <br /> sP "P <br /> cTformatlon'tth'e-SsY.1d.JOni2UtN GovNTY EN..xR[toNMBNTALIi6A2TH DEPARTMENT as soon as It-is available andatthe same time it <br /> .............' m•• — <br /> �3iD�Ide21Yo'Yhe`or,ztryrepresentattVe <br /> Yr <br /> RECEIVED <br /> f <br /> AUG.3.0 <br /> - C <br /> - -- — . zo)3 <br /> QUIN <br /> HEALtTH DEPARTMJOA <br /> ENT <br /> lA�tTCETED: :Y �„45 <br /> . ... .EMPLOYEE.#: DATE: <br /> .�'., tGN Ib'�tG'✓ s ��p. ' 'E'IfdPLOYEE#:.:._ _ -DATL <br /> �to66v(ce•Compteted (It,atreadYcompteted): SERVICECODE: 1, %2 PIE!2 <br /> ¢ Amount Paid 3 �pv. Payment Date YVI, 3' <br /> nTTpe s Invoice Cheek# 6 3 Received 6 <br /> f <br />